Healthcare Provider Details

I. General information

NPI: 1902132749
Provider Name (Legal Business Name): SUMMERVILLE AT ST. AUGUSTINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MARINER HEALTH WAY
ST AUGUSTINE FL
32086-3215
US

IV. Provider business mailing address

150 MARINER HEALTH WAY
ST AUGUSTINE FL
32086-3215
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-9988
  • Fax:
Mailing address:
  • Phone: 904-794-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9908
License Number StateFL

VIII. Authorized Official

Name: ANNA MUNOZ
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 414-918-5443